Failure to Notify Family of Resident's Fall and Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's representative following a fall with injury and subsequent hospital transfer. The incident involved a resident who, during care, rolled out of bed while staff attempted to place a Hoyer pad, resulting in a right knee distal fracture. Documentation in the medical record confirmed that the physician was notified, an x-ray was ordered, and the resident was transferred to the emergency room for evaluation. However, there was no documentation that the resident's family was informed of the fall, injury, or hospital transfer. Interviews with facility leadership revealed that staff practice was not to notify family members if the resident was cognitively intact and designated as their own responsible party, unless the resident specifically requested family notification. The resident confirmed that the facility had permission to notify their daughter about any issues, but this was not done. Both the ADON and DON stated that communication with family was not standard for residents responsible for themselves, even in cases of significant injury and pain.